What Makes "Good" Psychotherapy?

Proposing three conditions

Made with DALL·E 2. Prompt: “a painting of a therapist and client in therapy, where the client has just had a light-bulb moment”

Dr. Jonathan Shedler wrote a fantastic article on How to Choose a Therapist. In it, he describes the dynamic nature of psychotherapy, and the key elements of the therapeutic alliance:

Many therapists speak of the “therapeutic alliance" but fewer seem to understand what a therapeutic alliance entails. It does not just mean that you feel a connection. It is not an alliance based on just anything. A therapeutic alliance is an alliance based on a shared purpose—around the work you are there to do. It has three elements:

1. There is a connection.

2. There is mutual agreement about the purpose of therapy.

3. There is mutual agreement about the methods you will use to achieve this purpose.

All three elements are necessary. I often see the first without the other two. That makes for a warm and supportive relationship but not for meaningful psychological change.

Dr. Shedler makes the point that without a good therapeutic alliance (working relationship between the client and the therapist), effective psychotherapy is just not possible, as there is a lack of direction in where the therapy “should go”. Within this, there are hints of something akin to a disingenuous relationship, if one of these conditions are not met. Meaning, its not truly psychotherapy if there is no connection, working idea of what’s wrong (mutual purpose), or how to go about working towards a solution (methods).

Dr. Shedler proposed these three characteristics as required for working towards building a positive therapeutic alliance with the client. Here, I propose three parallel (and overlapping) conditions that I believe must be met, if therapy has any hope of being successful. “Good therapy” is defined as therapy that is helpful for the client in achieving their desired goals. To set up the potential for successful outcomes in therapy, in my opinion, therapy should be:

1) Dyadic, 2) Emergent, and 3) Meaningful.

Dyadic

It is often the case that the client doesn’t fully understand what even is the problem, and the therapist’s initial hunches likely don’t fully capture the complexity of the presenting problem, either! Meaning, the client might have difficulty articulating their experience and getting to the root of the problem, while the therapist won’t be able to figure out the problem without some feedback from the client, either. For example:

Client: I’ve been having difficulty sleeping this past year, and its really affected my relationship with my partner

*Therapist starts conceptualizing the presenting problems as sleep/relationship issues*

Therapist: It sounds like your irregular sleeping patterns have really made it difficult to connect with you partner.

Client: Yes, but honestly I’ve been having a lot of bad thoughts at night that keep me from falling asleep.

Therapist: Mhm, I can understand how you might feel overwhelmed at the thought of your relationship with your partner changing, and feeling out of sync with them.

Client: Oh, actually I’ve just been really tired and so my partner gets irritated when I seem inattentive during the day. The thoughts at night are really about this new job, my boss at work is giving me a hard time…

*Therapist updates their prior assumptions, and re-conceptualizes the presenting problems as sleep issues affected by work-related stress, which are affecting the client’s relationship with their partner*

This is a brief, but very typical example of how the client and therapist bring themselves to therapy, but the heart of the issue begins to be uncovered only through a dyadic process between client and therapist. This back-and-forth is the crux of the first condition for good therapy. Without this ability for open feedback and dialogue, the client and therapist might find themselves hiding parts of themselves from each other, or project these parts onto the other person (see transference and counter-transference). The “real problem” might never emerge. This dyadic relationship is really the outcome of Dr. Shedler’s three characteristics of the therapeutic alliance. Without a trusting and working alliance, the safe space to explore potential problems and even figure out what is going on, quickly gets lost.

Arriving at a place where verbal, affective, and emotional congruence is maintained between client-therapist takes work, and since the dyadic relationship is ongoing and dynamic, it is prone to rupture. However, this relationship also has potential for repair. Like any relationship, the therapeutic alliance is difficult to maintain, and requires contorted effort. This is not just the starting point of where the “real work” begins, but a lot of the “work” is actually done in this step.

Emergent

The second condition of good therapy is that the therapy is emergent.

To use a metaphor here, if we treat the understanding of the problem — from both client’s and therapist’s perspective, as elements in the periodic table, the dyadic nature of therapy is what brings the elements close enough to react to each other. The chemical interaction represents the dyadic interaction between the client-therapist, and the outcome of the interaction is what we can call emergence.

If therapy is “good”, this emergence in the interaction between both client and therapist, might look like a breakthrough, increased awareness, higher tolerance, better understanding, integration of emotions, or re-framing of the presenting problem. This not only creates change in the client, but the active engagement and process of the therapist means both come out of the session as a slightly different people, than when they began the session!

If therapy is emergent, it means that the client couldn’t have arrived there alone, nor could the therapist have attuned to anything meaningful without a client in front of them. Both have experienced change (in small or major ways) by the act of therapeutic engagement.

There’s hydrogen atoms, and there’s oxygen atoms, but the unique interaction of both, under very specific conditions, allows for the formation of water molecules. Revisiting the metaphor, hydrogen and oxygen atoms don’t just naturally turn into water if you put them in a room, but they must interact in a way where energy must be supplied to break the covalent bonds that hold H2 and O2 molecules together. This energy is the dyadic process that leads to the emergent outcome of change in therapy. Such a change can only take place though, if the therapy is indeed meaningful.

Meaningful

The final condition is that good therapy must be meaningful. I wanted to revisit a brief tweet storm by Dr. Shedler, where he poses two simple questions that can determine if the therapy one is receiving, is meaningful psychotherapy:

1. Think of a time you were upset with your therapist. Did you tell them? y/n

no = this is not meaningful psychotherapy
yes= this may be meaningful psychotherapy

2. Did therapist respond with non-defensive curiosity & genuine interest in hearing & further exploring your thoughts/ feelings/experience? y/n

no = this is not meaningful psychotherapy
yes= this may be meaningful psychotherapy

*Note that non-defensive interest in hearing and further exploring is not same as apologizing—which too often bypasses process of exploring & understanding your experience more deeply, and can makes it more difficult for you to express further anger, disappointment, hurt, etc.

Meaningful psychotherapy is framed as psychotherapy that helps facilitate the space for error-corrective judgement. In other words, the two questions above, hint at a) the client’s comfort and ability to openly express themselves honestly to the therapist, and b) the therapist’s comfort in working with the client’s reaction, in a reflexive way where the experience is further explored with curiosity, and not immediately shot down. Through this process, there was an “error” (something upsetting to the client) that has the space to be “corrected” (addressed and processed with the therapist, not necessarily corrected in a literal sense).

In this way, meaningful psychotherapy happens when there is enough transparency and dyadic communication between client-therapist to overcome inevitable hurdles, pitfalls, miscommunications, or ruptures in the working therapeutic alliance. If done right, ruptures have the potential for repair, and this process of meaningful exploration can act as a model for the client in how they can explore rupture and repair in their other relationships.

Conclusion

In conclusion, my definition of “good therapy” includes the dyadic relationship between client-therapist, with the possibility for emergent outcomes not otherwise possible outside of the therapeutic relationship. These processes and outcomes are facilitated in a way where there is trust and space for meaningful error-correction and repair from ruptures. In this way, there is room for trust (dyadic), transformation (emergent), and transparency (meaningful) in the therapeutic process. These are, in my opinion, the three conditions required for “good” psychotherapy to begin to occur.